The Center for Medicare & Medicaid Services (CMS) has issued its 2016 Hospital Outpatient Prospective System (HOPPS) payment recommendation for minimally invasive surgery sacroiliac joint fusion (MIS SI). According to a SI-BONE press release, this proposed payment provides an increased outpatient payment when billing CPT 27279 from US$9,266 to US$10,538. This represents an increase of US$1,272 or 14%, and will become effective on January 1, 2016.

CMS also announced an increase in the physician reimbursement for MIS SI joint fusion procedures when billing CPT in their Medicare Physician Fee Schedule (MPFS). The increase should be 25%, representing a rise from the current US average, US$577, to US$722, also effective January 1, 2016.

“With increased reimbursement for both the surgeon and facility, CMS continues to recognise the increasing value of MIS SI joint fusion,” says Michael Mydra, vice president of Health Outcomes & Reimbursement at SI-BONE. “We believe that the iFuse Implant System fits strategically with the overall goals of the Affordable Care Act (ACA) by providing a safe, effective, and cost beneficial solution for the treatment of low back pain due to degenerative sacroiliitis and SI joint disruption.”

In addition to the 2016 hospital outpatient and physician payment increases for MIS SI joint fusion, Medicare Administrative Contractor (MAC) Wisconsin Physician Services (WPS), covering the six US states of Iowa, Indiana, Kansas, Michigan, Missouri and Nebraska, published a positive local coverage determination (LCD) that provides coverage beginning on December 17. According to SI-BONE, the decision by WPS to establish coverage for the procedure was based on a robust body of clinical evidence—over 95% of which is based on the company’s iFuse Implant System­—that shows significant reduction in pain and improvement in quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption.

Two additional MACs have also released positive draft LCDs for MIS SI joint fusion. The first is National Government Services (NGS) covering ten US states including Connecticut, Illinois, Massachusetts, Maine, Minnesota, New Hampshire, New York, Rhode Island, Vermont and Wisconsin and the second is CGS Administrators (CGS) which covers Ohio and Kentucky.

Upon finalisation of the draft LCDs for NGS and CGS, 49 out of US 50 states will cover MIS SI joint fusion providing coverage for 48 million Medicare beneficiaries in the United States.

“Once these 3 MACs implement coverage, seven of the eight MACs will have positive coverage for MIS SI joint fusion for over 98% of Medicare beneficiaries in the USA. We believe that the clinical and economic evidence supporting the iFuse Implant System as a safe and effective treatment for patients suffering from degenerative sacroiliitis or SI joint disruption has demonstrated that these patients deserve access to the procedure,” said Jeffrey Dunn, president and CEO of SI-BONE.